NOW CPOC Revision Request Form

Instructions

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Purpose

The purpose of this form is to document revisions to the budgeted waiver services as the needs of the individual participant change during the CPOC year. Support Coordinators shall submit revision requests in accordance with the policies and procedures as outlined in the NOW manual, the Case Management manual, the Guidelines for Planning Manual and as updated by written notification from the OCDD Program Offices.

Revision Request Form - Page 1 (Budget Page)

Page 1 of the Revision Request form indicates: (1) waiver participant identifying information, (2) requested time line for the revision changes, (3) justification for the revision request, (4) signatures of all parties affected by the revision, including the transferring provider if any (5) identification of the waiver service provider’s Medicaid vendor number (provider #), (6) a summation of all CPOC cost changes effected by the revision, (7)OCDD’ designation of the effective start date, and (8)OCDD’ approval signature of the revision request.

Revision #

From the CPOC start date, each revision submitted toOCDD must be numbered consecutively for each CPOC year. Enter on this line the number of this revision request.

Attached Supporting Documentation as Needed

If the waiver participant/authorized representative is requesting changes for the remainder of the CPOC year, the change(s) SHALL be documented in the body of the CPOC and attached to the revision form. These changes shall be reflected in accordance with how the participant defines or prioritizes his/her personal outcomes/goals and/or service needs, and be submitted with the revision form. This request form does not change the annual CPOC dates.

Examples of attachments may include:

  • Documented changes in the body of the CPOC
  • Environmental modification and/or assistive device forms, including bids and diagrams
  • Physician approved delegation of medication administration forms
  • Service provider Freedom of Choice (FOC) Forms
  • Home Health Plan of Care (POC)
  • Hospice POC

Recipient Name

The participant’s full legal name must be on the CPOC revision form. Please enter last name - comma - first name. If the individual prefers to use a nick name, this may be entered in brackets after the first name.

Medicaid I.D. Number

Enter the Participant’s 13-digit Medicaid Identification (ID) Number. Please do not enter a Control Card Number (e.g. 7770000...... ).

Last 4 Digits of Social Security No.

The number entered on this line is the last four digits of the individual’s Social Security Number.

Requested Start Date

Enter the requested start date for service changes to begin. (NOTE: The requested start date may be different from the approved effective date as in cases of emergency submission.)

Justification for Revision

Enter a detailed explanation for the needed change in authorized waiver services. If this is an urgent revision the justification should also address why this is an urgent situation.

Routine Revisions

Whenever possible, additional service needs should be anticipated and planned for in the original CPOC. When an unanticipated need is identified 10 or more business days prior to the change, a CPOC Revision Request should be submitted and will be processed within 10 business days. If an unanticipated need is identified after the 10th business day the CPOC Revision Request must be identified as “Urgent”, and the additional responsibilities for Provider and Support Coordinator must be assumed (see below).

Urgent

This box should be checked if the revision is an urgent request. An urgent need exists when there is an unplanned/unpredictable event which requires urgent changes(s) to waiver services and/or changes in the service provider. Urgent changes are changes that must begin less than 10 business days from receipt by theOCDD Regional Office.

If a revision meets the above criteria for urgent:

  1. It is the responsibility of the waiver service provider to contact the Support Coordinator about the situation.
  1. It is the responsibility of the Support Coordinator to telephone theOCDD Regional Office and informOCDD that there is an urgent request for Prior Authorization (P.A.). The Support Coordinator then must submit to theOCDD Regional Office a revision request as soon as possible on the date of notice.
  1. When the Support Coordinator telephones the OCDD office about the urgent request, the incoming call from the Support Coordinator will be directed to thestaff person who will handle the revision. All urgent calls for emergency revisions will be rotated to anOCDD staff member according to the Region’s policy.
  1. The Support Coordinator must be available to theOCDD staff member who will be handling the emergency request. This is necessary in the event additional information is needed to justify approval of the revision, or in the event there are corrections needed. If the Support Coordinator will not be available arrangements should be made for a Support Coordination Supervisor to be available to handle immediate requests for information or corrections.
  1. If an urgent service need occurs during non-business hours, Emergency changes must be submitted within 24 hours or by the close of the next working day. It is also the responsibility of the Support Coordinator to call, to ensure that the request has been received and is being processed.
  1. Whenever possible the urgent revision request should have the participant/authorized representative and the service providers’ signatures on the completed revision form. When it is not possible to obtain all signatures, the incomplete revision request form should be sent to OCDD according to the instructions above, and a fully signed copy must be sent to OCDD by the fifth working day. If a fully signed copy is not received by the fifth working day, the revision request will be forwarded to the Support Coordination Program Manager with the recommendations by the Regional Office (services can not continue without a CPOC verified by the participant/authorized representative and service provider).
  1. When an urgent CPOC revision request is approved, the OCDD Regional Office staff will call Statistical Resources, Incorporated (SRI) to notify them that an urgent request for PA is being faxed. OCDD will request that the PA be issued promptly. OCDD will also provide a copy of the approvals to SRI and the Support Coordinator.
  1. It is the responsibility of the provider to have prior authorization for all services. In the case of an urgent need after hours, the prior authorization must be obtained by the close of the following business day. If the Support Coordinator cannot be contacted, the Support Coordination Supervisor should be contacted. If results are still not obtained, theHealth Standards complaint line should be called.

Shared Support

Check this box if the individual is receiving shared supports and submit with the CPOC revision for the other person/person sharing supports.

CPOC: BEGIN DATE

Enter the approved begin date of the current full CPOC.

CPOC: END DATE

Enter the traditional annual ending date of the CPOC year. This date does not change.

Signature Box

AFTER the form is completed, it shall be signed to indicate agreement with the requested changes entered on pages 1 and 2 of this revision request form.

Recipient/Authorized Representative signs and enters the date they signed.

Waiver Service Provider signs and enters the date they signed.

Support Coordinator signs and enters the date they signed.

The Support Coordinator is to also enter the full name of their Support Coordination Agency.

CPOC Revision Budget Table (page 1)

This table will contain a summation of all costs and PA changes entered on the Weekly Schedule Changes Table and the Alternate Schedule Changes Table on Page2.

Column 1 -Service Provider Name

Enter the name of the Waiver Service Provider which will provide the listed service and to which SRI will issue the change(s) in PAs. (Note: All service providers affected by the change must be listed – this includes a service provider who will stop providing services).

Column 2 - Service Provider No.

Enter the Service Provider’s Medicaid Vendor Number for the listed service. Be sure to enter the correct number for the correct service.

Column 3 - Service Description

Enter an abbreviated description of the type of waiver service (e.g. ACS, CC, PER).

Column 4 - Service Procedure Code

This is the billing code assigned to the specific service. (Refer to the most recently issued service/procedure code/rate document).

Column 5 - Modifier

Enter the billing code modifier assigned to the service. (Refer to the most recently issued service/procedure code/rate document).

Column 6 - Total # of Revision Units (+ or -)

Enter the cumulative total of changes (+ and/or -) entered in the Weekly Schedule Changes Table and the Alternate Schedule Changes Table (Page 2), for the same service provider and the same service type.

Column 7 - Cost/Rate Per Unit

Enter the assigned cost per service unit. (Refer to the most recently issued service/procedure code/rate document).

Column 8 - Total Revision Cost Per Service (+ or -)

Enter the number arrived at (+ and/or -) when the number in Column 6 is multiplied by the number in column 7. (Column 8 = Column 6 x Column 7).

TOTAL COST OF REVISION

Enter the sum of all figures in Column 8. (This figure (+ and/or -) reflects the change in the CPOC year costs as a result of this revision request).

OCDD USE ONLY

Upon review and approval of the CPOC revision request, a OCDD Certification Specialist shall assign an effective date for the revision to begin. The OCDD Certification Specialist will also sign, initial, and enter the date of signature.

Schedule Page – Page 2

Revision #

Enter the same revision number (#) that was entered on page 1 of this Revision Request Form. It is very important that this number be entered correctly as it is the entry that identifies this page as part of the current revision request.

Recipient’s Name

The participant’s full legal name must be on this page 2 of the CPOC Revision Form. Please enter last name - comma - first name. If the individual prefers to use a nick name, this may be entered in brackets after the first name.

Last 4 Digits of the Social Security Number

The number entered on this line is the last four digits of the individual’s Social Security Number.

Weekly Schedule Changes

Enter on this table changes (+ or -) that are consistent from week to week and extend through the end of the CPOC year. Intermittent changes to service units are not entered in this schedule. A separate line entry is to be completed for each provider and for each service type.

Column 1 -Service Provider Name

Enter the name of the Waiver Service Provider which will provide the listed service and to which SRI will issue the change(s) in PAs. (Note: All service providers affected by the change must be listed – this includes a service provider who will stop providing services).

Column 2 - Service Procedure Code

This is the billing code assigned to the specific service. (Refer to the most recently issued service/procedure code/rate document).

Column 3 - Modifier

Enter the billing code modifier assigned to service. (Refer to the most recently issued service/procedure code/rate document).

Columns A through G

Enter the number of units to be changed (+ or -), for each day of the week.

Column H

Enter the sum (+ or -) of Columns A through G.

Column I

Enter the total number of full weeks (Monday through Sunday), that are included in the time range from the requested date of the revision through the end date of the CPOC year.

Column J

Enter the total of the number in column H multiplied by the number in column I. (J= H x I)

Column K

Enter the partial week units (+ or -) in this column. Determine the number of units in partial week(s) (less than Monday through Sunday), included in the requested time range at the beginning and/or end of this CPOC revision time range. (This time range is from the requested start date through the end of the CPOC year.

Column L

Enter the sum of columns J and K. (L = J + K)

Alternate Schedule Changes

Enter changes in service units or providers that are not consistent from week to week and/or do not extend through the remainder of the CPOC year.

Column 1 -Service Provider Name

Enter the name of the Waiver Service Provider which will provide the listed service and to which SRI will issue the change(s) in PA’s.

Column 2 - Service Procedure Code

This is the billing code assigned to the specific service. (Refer to the most recently issued service/procedure code/rate document).

Column 3 - Modifier

Enter the billing code modifier assigned to service. (Refer to the most recently issued service/procedure code/rate document).

Column A

At the top of the column enter the current CPOC begin date. If the CPOC begin date is not the first date of a fiscal year quarter, Column A will identify a partial quarter at the beginning of the CPOC year. This column will contain changes that occur from the Begin date of the CPOC to (not through) the start date of the next consecutive fiscal year quarter. (April 1st, July 1st, October 1st, or January 1st).

If alternate changes occur during this partial quarter enter the following information

  • If there are any service unit or provider changes that occur during this partial quarter, enter the number of service unit changes (+ or).

Columns B, C and D

At the top of each of these columns enter the month and year of each of the next three consecutive fiscal year quarters. Dates at the top of this column should be 01/YR, 04/YR, 07/YR, or 10/YR (not necessarily starting in that order as the CPOC start date may have been later in the fiscal year.)

If alternate changes occur during these full fiscal year quarters enter the following information:

  • If there are any service unit or provider changes that occur during these full fiscal year quarters, enter the number of service unit changes ( + or -).

Column E

Enter the current CPOC end date. If the CPOC end date is not the last date of a fiscal year quarter, Column E will identify a partial quarter at the end of the CPOC year.

This column will contain changes that occur from the beginning of this consecutive ( to Column D ) fiscal year quarter ( January 1st, April 1st, July 1st, or October 1st ) through the CPOC end date.

If alternate changes occur during this partial quarter enter the following information

  • If there are any service unit or provider changes that occur during this partial quarter, enter the number of service unit changes (+ or).

Column F

Enter the sum of service unit changes (+ or -) that were entered in columns A through E.

(F = A + B + C + D + E)

The summation of changes entered in the Weekly Schedule Change Table and the Alternate Schedule Change Table must also be included on page 1 in the BUDGET Change Table.

Issued March 25, 2009OCDDWSS-P-09-002

Obseletes BCSS-PI-04-010 Page 1 of 8